A trainee on Triage: a brave new paradigm for acute inpatient units?

Here is a piece I wrote for the RCPsych London division December Newsletter. It’s about Triage ward on the Ladywell unit in Lewisham.

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Triage ward is one of five general adult wards serving the inpatient psychiatric needs of the Lewisham area. It is based in Lewisham hospital and is part of the Ladywell Unit which in turn is part of the South London and Maudsley NHS Trust (SLAM). Judging by the number of visitors we have had to the ward whilst I have been working here, there is a great deal of interest in the way we do things.

Triage ward is part of an unusual model for managing psychiatric admissions, and one that is soon to be implemented across SLAM. As a ward it acts as a single point of admission for all patients who enter the Ladywell unit. It is aimed that patients will stay for a maximum of two weeks, whilst their needs are considered. If, after this time, they need to continue as an inpatient for a further spell, they are then transferred to a longer stay ward. This model contrasts to the established paradigm whereby ward allocation is sectorized, where patients are on admission immediately assigned to wards depending on their postcode or the location of their general practitioner and there is no envisaged limit on admission duration. The impetus for establishing Triage was a desire to address common problems found within psychiatric in-patient units where wards are busy and overcrowded, leading to patient overspill into the private sector and a high staff turnover. It was established in 2003 by Dr Martin Baggaley, who is now medical director of SLAM.

Triage is a mixed ward and its maximum capacity is 16 patients. Asides having an airlock and being more secure, it looks much like any other inpatient psychiatric ward, although newer than some. The provision of staff is generous compared to other sites and asides a contingent of skilled nursing staff, there are two CT1-3s doctors, a ST4 doctor, two part time consultants (full time equivalent), and a social worker.

Triage’s aim is that, after admission, patients should have their needs met and be discharged to the community or another ward as quickly as possible and much of what we do has this goal in mind. The turnover of patients is extremely high and amounts to 920 patients per year. There can be as many as four new patients in a day across a wide ethnic mix. Some patients seem to go before one has even met them and after a returning from a week’s annual leave the ward’s inpatients will have almost completely changed. This constant flux means it’s difficult to form a rapport with any of the patients. The life of a junior doctor is very busy and a recent new duty is a completion of an OPCRIT computer based diagnostic assessment for each patient. Unlike other SHO jobs, time constraints mean that we don’t complete the patient discharge summaries and this responsibility is passed onto the ST4 trainees. Fellow CT trainees on other wards are jealous of this concession!

A lot of my work is administrative, which can be dull but in compensation there is plenty of opportunity to learn at the consultant lead ward round, which is held daily to ensure swift patient movement through the system. Here my role is to make interview and management plan notes and this is done on a computer terminal which is projected for all to read. With two different consultants it is possible to observe different interviewing styles. I have found interviewing more difficult than I expected and my ability to undertake a mental state examination has much improved. The presentations of our patients are very varied and sometimes the ward rounds can be quite dramatic. About half of our patients are under section at any one time and, much is as one might expect, depressive, psychotic and personality disordered presentations predominate. We work closely with the local crisis resolution service and a member of their team is often present. The downside of such regular ward rounds is that with senior doctors so regularly available, there’s little latitude for independent thought.

Triage might perhaps appear foreboding to the uninitiated. The ward and staff base can feel as busy and noisy as general medical wards post take, but there are plenty of calm periods too. The staff base is shared between doctors and nurses. This makes for good multi-disciplinary communication and although we’re short of computer terminals this is never a cause of friction. I have however become resigned to our second printer being permanently broken. There can be an air of unpredictability and the ward panic alarm is activated a lot. I’ve never felt personally threatened, although it’s not unheard of for a member of the nursing staff to be assaulted.

Patient treatment is predominantly medication based and I think it’s a shame that there are no psychologists on the ward, but there is a social worker available to address social needs, which oftentimes is the most important thing. The air conditioning we have is a mixed blessing as patients often complain of being cold in bed at night. The ward environment is rather boring for the patients, although there is a daily newspaper and a table tennis table; the nature of the disorders with which we deal means that some patients, who might wish for peace and quiet, are disturbed by other more vociferous residents.

Overall my experience of working on Triage ward has been very positive. On other wards on which I have been employed patients can sometimes be admitted for several days before they are seen by a consultant, an experience that can be very frustrating. However on Triage ward, with its daily ward round, things move much more quickly and it is also hard not be impressed by the financial savings Triage has bought to the SLAM trust, as it is now almost unheard of for a Ladywell patient to be accommodated in the private sector.

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5 Responses to “A trainee on Triage: a brave new paradigm for acute inpatient units?”

Hi..I agree with what you said about it being a positive experience working at Triage ward. It was my first post working there as an SHO in 2005 and I still think that what I learnt there was fantastic! Till date i can draw on my expereinces there in dealing with a variety of cases and from the way other memebers of team dealt with it.Its was especially a good nursing team and experinenced cosultants who were fun to work with !Ahh..memories!:-)

My Sister has been staying at Triage ward and from what I see the staff do nothing the rooms are a total disgrace and the other day a patient was getting my sisters hot meal why the staff and the manager just sat back and her room was dirty and smelling of pooh and toilet was blocked it was like that for at least sat evening/sunday evening. my other sister visited our sister early sat evening and the revolting smell was still there a day and even
the cleaners are lazy like the nursing and management staff they just want an easy life they do not seem caring and helpful to me you should be ashamed and you should hope you do not need help like my sisters needs at this present time

Absolute disgrace of a unit.
A mental health unit Where sectioning means patients are granted 30mins alone to smoke off the hospital grounds unescorted.

These patients are seriously unwell and many just need the appropriate help they require , ward staff are liars and really don’t actually care about the safety of the patient or the family and carers let alone even consider the general public .. to think how dangerous my relative is I would have expected a lot more stringent rules and regulations.
What’s the point in issuing any sections of the mental health act when the very building and staff detaining the patients is so lacking in authority or basic human well being.